Role Development of Nurses for Technology …...91 reported, but only among nurses working in hospitals (Benner, Tanner, & Chesla, 2009) and the 92 community (Clancy, Oyefeso, & Ghodse,

TitleRole Development of Nurses for Technology-DependentChildren Attending Mainstream Schools in Japan(Dissertation_全文 )

Author(s) Shimizu, Fumie

Citation Kyoto University (京都大学)

Issue Date 2015-03-23

URL https://doi.org/10.14989/doctor.k18909

Right 許諾条件により本文は2016/03/20に公開; 許諾条件により要旨は2015/06/23に公開(2015/08/04公開日変更)

Type Thesis or Dissertation

Textversion ETD

Kyoto University

NURSES FOR TECHNOLOGY-DEPENDENT CHILDREN 1

Journal: Journal for Specialists in Pediatric Nursing 【主論文】 1

Role Development of Nurses for Technology-Dependent Children Attending Mainstream 2

Schools in Japan 3

4

Fumie Shimizu and Machiko Suzuki 5

Fumie Shimizu, MNS, RN, PHN, MW, is a PhD Student, and Machiko Suzuki, PhD, RN, PHN, 6

is Professor, Department of Human Health Science, Graduate School of Medicine, Kyoto 7

University, Japan. 8

9

10

Acknowledgments. FS designed the study, conducted individual interviews, analyzed the data 11

and interpreted the findings, and drafted and submitted the manuscript. MS supervised the study, 12

analyzed the data and interpreted the findings, and provided guidance. 13

We would like to thank participants, the staff of the boards of education, and school 14

administrators. We are grateful to Professor Chikage Tsuzuki of Kobe City College of Nursing, 15

Professor Yasuhito Kinoshita of Rikkyo University, and Professor Hitomi Katsuda of Gifu 16

College of Nursing for supervising this study. This study was supported by a grant from the 17

Yuumi Memorial Foundation for Home Health Care. 18

19

Disclosure: The authors report no actual or potential conflicts of interest. 20

Author contact: [email protected], with a copy to the Editor: 21

[email protected] 22

23

mailto:[email protected]


Abstract 24

Purpose 25

To describe the role development of nurses caring for medical technology-dependent children 26

attending Japanese mainstream schools. 27

Design and Methods 28

Semi-structured interviews with 21 nurses caring for technology-dependent children were 29

conducted and analyzed using the modified grounded theory approach. 30

Results 31

Nurses developed roles centered on maintaining technology-dependent children’s physical health 32

to support children’s learning with each other, through building relationships, learning how to 33

interact with children, understanding the children and the school community, and realizing the 34

meaning of supporting technology-dependent children. 35

Practice Implications 36

These findings support nurses to build relationships of mutual trust with teachers and children, 37

and learn on the job in mainstream schools. 38

Search terms: Mainstream school, modified grounded theory approach, nurse, role development, 39

technology-dependent children 40

41


Role Development of Nurses for Technology-Dependent Children Attending Mainstream 42

Schools in Japan 43

The importance of inclusive education, in which all children learn together regardless of 44

disability, has been demonstrated worldwide (United Nations Educational, Scientific and 45

Cultural Organization, 2009). In some countries, children dependent on life-sustaining medical 46

technology attend mainstream schools. A technology-dependent (TD) child has been defined as 47

“one who needs both a medical device to compensate for the loss of a vital body function and 48

substantial and ongoing nursing care to avert death or further disability” (United States Congress, 49

Office of Technology Assessment [OTA], 1987). TD children are dependent on mechanical 50

ventilators, intravenous administration of nutritional substances or drugs, tracheotomy tubes, 51

suctioning, oxygen support, tube feedings, urinary catheters, and/or colostomy bags (OTA, 1987). 52

In the United States and the United Kingdom, health care assistants or nurse’s aides—who do not 53

have registered nurses’ licenses—provide nursing care for TD children during the school day 54

under the supervision of school nurses (Heaton, Noyes, Sloper, & Shah, 2005; Raymond, 2009). 55

Some TD children’s participation in school activities is limited because of a shortage of trained 56

care providers in mainstream schools and the difficulty of managing a care schedule on a school 57

timetable (Heaton et al., 2005; Kirk, 2010). 58

In Japanese elementary and junior high special-needs schools, the number of TD children 59

has increased by 1,000, or 20.5%, between 2008 and 2013 (from 4,882 in 2008; Japan Ministry 60

of Education, Culture, Sports, Science, and Technology [MEXT], 2009; 2014); yet, only 813 TD 61

children attended mainstream elementary and junior high schools in 2013 (data from 2008 is not 62

available for comparison; MEXT, 2014). This number, although currently low, is expected to 63

increase as mainstreaming increases. Each mainstream school usually has one or two school 64


nurses. Furthermore, in 2012, 102 boards of education—which govern educational matters in 65

mainstream schools—employed 295 nurses without school nurses’ licenses as contractual 66

employees to provide nursing care for TD children attending mainstream schools; 46.3% of these 67

boards required the nurses to work as special needs education supporters who assist children with 68

disabilities in studying and school activities, in addition to providing nursing care (Shimizu, 69

2014). In addition, teachers needed these nurses to maintain TD children’s health and safety as 70

well as serve as members of the educational team (Shimizu & Katsuda, 2014). Thus, these nurses 71

were expected to play roles related to education that were unlike any they had experienced 72

before. Nurses are being employed in workplaces that previously had no place for them, and this 73

is similarly expanding their roles and required duties. This indicates a need for nurses to develop 74

their professional roles (All-Party Parliamentary Group on Global Health and the Africa All-75

Party Parliamentary Group, 2012). 76

The aim of this study was to describe the role development of nurses who provide 77

nursing care to TD children attending mainstream schools, which occurs through interactions 78

with teachers, school nurses, children, and parents. This study will be useful not only for these 79

nurses but also for policymakers seeking to realize inclusive education who are examining and 80

improving care systems in mainstream schools. 81

Literature Review 82

Role development is defined as an emergent process, which can be influenced by pre-83

defined role expectations, changing organizational requirements, individual needs, and ongoing 84

interactions among actors in a particular role set (Miller, Joseph, & Apker, 2000). Some of the 85

factors that affect nurses’ role development include skills, knowledge development (Ellis & 86

Chater, 2012; Rasmussen, Henderson, & Muir-Cochrane, 2014), turbulent interactions (Heitz, 87


Steiner, & Burman, 2004), personal characteristics, previous experience (Jones, 2005), support 88

from others (Ellis & Chater, 2012; Jones, 2005), and communication (Boström, Hörnsten, 89

Lundman, Stenlund, & Isaksson, 2013). The stages of nurses’ role development have been 90

reported, but only among nurses working in hospitals (Benner, Tanner, & Chesla, 2009) and the 91

community (Clancy, Oyefeso, & Ghodse, 2006). 92

Few reports have detailed the role development of school nurses or nurses caring for TD 93

children in mainstream schools. Simmons (2002) investigated school nurses’ perceptions of 94

professional autonomy and found role acquisition to be one important aspect of that autonomy. 95

Furthermore, Simmons reported that experienced school nurses clarified their roles after 96

developing their own philosophies regarding school nursing roles and responsibilities. However, 97

Simmons did not clarify how these nurses came to integrate their knowledge, skill, and personal 98

qualities, which are integral to role development. Few examples could be found that related to 99

the role development of nurses caring for TD children attending mainstream schools. 100

Methods 101

Participants 102

Participants were nurses employed by the local boards of education to provide nursing 103

care to TD children attending Japanese mainstream schools. After obtaining approval for this 104

study from the Medical Ethics Committee of Kyoto University and the boards of education, we 105

telephoned and sent letters to school principals and, after explaining the study, we asked them to 106

pass on the recruitment letter, response sheet, and a return envelope to nurses caring for TD 107

children at their schools. Nurses could indicate their agreement to participate via mail or email. 108

In 2012, the first author surveyed all educational boards in Japan to ascertain the actual 109

conditions of nurses employed to care for TD children attending mainstream schools (Shimizu, 110


2014). Based on these results, purposive sampling was used to select nurses who fit the inclusion 111

criteria. Nurses’ inclusion criteria were (1) having worked for more than 2 years in mainstream 112

schools, (2) working more than 3 days per week at the school, and (3) not being employed as a 113

special education supporter or school nurse. More than 2 years of experience was required 114

because competent nurses have 2–3 years of work experience in the same clinical setting (Benner 115

et al., 2009). In Japan, the efforts of municipal educational boards relating to special needs 116

education differ depending on the municipality type and the size of the municipal jurisdiction 117

(Matsumura et al., 2009); therefore, nurses were selected from different geographical areas, with 118

widely varying municipality types and population sizes. We used theoretical sampling to select 119

nurses employed for the greatest length of time, who provided a variety of nursing care to TD 120

children in various grades. 121

Ethical Considerations 122

The Medical Ethics Committee of Kyoto University approved this study (Approval No. 123

E1513) and it conformed to the principles set forth by the Declaration of Helsinki. Before 124

interviewing, we explained the purpose of the study, the research methods, and the way the 125

results would be used, both verbally and in writing, to all participants. Participants were 126

informed that they could withdraw from the study at any time without penalty, and that 127

confidentiality was guaranteed. All participants provided consent for participation both verbally 128

and in writing. 129

Data Collection 130

A descriptive qualitative research design was used, and data were collected from 131

December 2012 to October 2013. Individual, semi-structured, open-ended interviews with nurses 132

were conducted by the first author (average duration: 71 min) using an interview guide (see 133


Figure 1). The first author is a nurse experienced in qualitative research and has cared for TD 134

children in mainstream schools for 5 years. The interview guide was developed using the first 135

author’s experience of providing nursing care for TD children in mainstream schools and pilot 136

interviews with two nurses (not included as data in this study). Interviews were conducted in the 137

participants’ schools, a room at a community center, or the participants' homes to protect their 138

privacy. The interviews were recorded on digital voice recorders, with the participants’ 139

permission, and then transcribed in Japanese. Throughout the process of conducting interviews 140

and analyzing the data, field notes were kept so that ideas and observations could be recorded. 141

When the interviews were conducted in the schools, the first author observed classrooms and the 142

care room and read nurses’ records with their permission. For reference, field notes were written 143

on the contents of the observations. 144

Data Analysis 145

The modified grounded theory approach (M-GTA; Kinoshita, 2003) was used for analysis. 146

The M-GTA is a qualitative analysis method derived from the original grounded theory approach 147

(Glaser & Strauss, 1967). In the M-GTA, the minimum analytical unit is the concept. Each 148

concept is derived from several pieces of data known as variations. Variations are collected after 149

reading interview transcripts repeatedly and obtaining their meaning. When a concept emerged, 150

similar or antithetical data related to the concept were examined to prevent arbitrary 151

interpretation. The relationships between concepts were examined and categories were deduced 152

from the related concepts. Then, the relationships between the categories were examined, and the 153

data comparison and analysis were repeated. Data analysis and collection were conducted 154

concurrently until theoretical saturation was reached. 155

This research was supervised by one researcher specialized in pediatric nursing and two 156


researchers specialized in M-GTA, to ensure trustworthiness and credibility. For member 157

checking, two feedback interviews were conducted. The analysis results were sent to 19 158

participants, and feedback was received from 15 participants. The feedback indicated that the 159

categories and concepts adequately reflected the perceptions of participants. 160

All categories, concepts, and quotations were originally in Japanese and analyzed as such. 161

The researcher translated them into English and a native English speaker verified the 162

comprehensibility and accuracy of the translations. 163

Results 164

Participant Characteristics 165

Twenty-one nurses participated; their characteristics are described in Table 1. Nurses 166

heard about these jobs from postings in job information sections of public relations magazines (n 167

= 9), through referrals/introductions from someone they knew (n = 8), or from the mothers of TD 168

children, who requested they apply for the job (n = 4). All nurses were employed by the boards 169

of education as contractual employees to provide nursing care for TD children in mainstream 170

schools. Most nurses (n = 19) worked in elementary schools and two worked in junior high 171

schools when the interviews were conducted. Schools were in 12 cities or towns ranging from 172

Hokkaido (in the north) to Kyushu (in the south). Eleven nurses worked every day when school 173

was in session. All nurses had experience working in elementary schools, and five of them had 174

experience working in junior high schools. Sixteen nurses took care of only one TD child and 175

five nurses took care of two or three TD children attending different mainstream schools at the 176

time of interview. In each mainstream school where nurses worked, there were one or two TD 177

children. The TD children needed multiple nursing care procedures including suctioning from 178

tracheotomies, the mouth, or the nose; intermittent catheterizations; tube feeding; intravenous 179


therapy; oxygen inhalation; stool extraction; colostomy care; intestinal lavage; ventilator therapy; 180

and inhalation. 181

Analysis 182

Twelve categories and 37 concepts were derived (Table 2). These categories were divided 183

into three stages: (1) maintaining children’s physical health, (2) maintaining children’s physical 184

and mental health, and (3) supporting children’s learning with each other. The core category was 185

realizing the meaning of supporting TD children. Nurses advanced from stage 1 to stage 2, and 186

then to stage 3. However, when nurses were confused about the nature of nursing care and 187

educational practices in stage 3, they went back to stage 2 in order to learn to interact with 188

children. 189

Stage 1: Maintaining children’s physical health. In this stage, nurses concentrated on 190

maintaining TD children’s physical health. However, they often experienced confusion in this 191

practice. This stage contains two categories: maintaining physical health and feeling confused. 192

Maintaining physical health. Nurses perceived themselves to have this role upon starting 193

to work in mainstream schools. They initially sought to concentrate on providing nursing care, 194

ensuring the safety of the TD children, monitoring the TD children’s physical condition, and 195

providing care for rehabilitation in order to maintain the TD children’s physical health. Because 196

nurses primarily believed themselves to be medical professionals, their perceived roles did not 197

differ from when they worked in hospitals. A nurse stated, “Basically, I think the role didn’t 198

change. I simply don’t work at a hospital [anymore]. I’m still a nurse. Therefore, my role is 199

providing nursing care safely and correctly.” 200

Feeling confused. Despite their initial clarity, nurses grew increasingly more confused 201

about their roles in the schools. Particularly, they felt confused about the extent and content of 202


nursing care and educational practices. When nurses were required to act in an educational 203

capacity (e.g., mediating children’s quarrels), they hesitated to act in that fashion: “When 204

children quarreled or the situation became unsafe for the TD child, I needed to settle and guide 205

them, but I hadn’t acquired an educational perspective. Therefore, I had difficulty.” Even after 206

gaining experience, some nurses remained confused about their role. Nurses worked as the sole 207

medical service staff member in the school, which made it difficult to consult anyone regarding 208

their practices; nurses did not always have confidence in their practices. One nurse said, “He [the 209

TD child] wanted to do something, but if he did, his physical condition might worsen. I couldn’t 210

decide. At that time, I asked the teacher about that, but I couldn’t get an answer that helped me 211

decide.” 212

Stage 2: Maintaining children’s physical and mental health. In this stage, nurses 213

attempted to build relationships of mutual trust and learn how to interact with children in order to 214

resolve their confusion. As a result, nurses came to maintain the TD children’s physical and 215

mental health in cooperation with teachers. This stage contains seven categories: building 216

relationships of mutual trust, learning how to interact with children, understanding the school 217

community, understanding the children, supporting self-care, becoming a secure base, and 218

bridging. 219

Building relationships of mutual trust. Nurses communicated positively and 220

attempted to build relationships of trust with teachers, school nurses, children, and parents. As a 221

result, they worked harmoniously in the school community and perceived themselves as 222

members of that community. Nurses realized that in order to work harmoniously in schools, they 223

needed to go beyond their nursing status when building relationships with teachers and children: 224

“If I said, ‘I don’t do this because I’m a nurse,’ I might not build good relationships in the 225


school.” They perceived that harmonizing with the school community was necessary to get 226

information for the TD child and facilitate communication between TD children and other 227

children. One nurse commented, “I thought that if I joined the children’s community and became 228

friendly with them, the other children will become friendly with her [the TD child].” Nurses 229

came to love the TD child as if he/she were their own child; nurses then had a desire for greater 230

interactions with the TD child; one nurse stated, “I feel as though he [the TD child] is my own 231

grandchild. Therefore, I want to take care of him more.” Nurses listened to and shared concerns 232

with parents in order to build relationships of mutual trust with them: “I tried to put myself in the 233

parents’ place and listen to and share parents’ concerns, just as in mental health care. A 234

relationship of mutual trust is necessary.” After building relationships of mutual trust with 235

teachers, school nurses, parents, and children, nurses felt a sense of security when they practiced. 236

Learning how to interact with children. Nurses learned how to care for TD children 237

through getting advice from parents and doctors, reading books, and participating in training. 238

They learned how to interact with children in an educational capacity from teachers and parents 239

by watching what teachers and parents did and by getting advice. One nurse said, “The teacher 240

advised me to keep my distance from her [the TD child] to promote her independence. I tended 241

to take care of her more than she really needed. With this advice, I realized [the truth].” Nurses 242

learned how TD children signaled their intentions and physical conditions through interaction 243

with these children and their parents and parents’ advice: 244

At first, I telephoned her [the TD child’s] mother many times to consult about her [the 245

child’s] physical condition. When she had a fever and muscle strain, I asked her mother. 246

Her mother told me why she had that physical condition. 247

As nurses learned how to interact with the TD children and other children, they developed a 248


deeper understanding of the school community and the TD children. 249

Understanding the school community. Nurses came to understand the mainstream school 250

context, eventually realizing that education was the priority in mainstream schools. This 251

realization was brought on by advice from teachers to restrict nurses’ medically oriented 252

viewpoints: “I was told by the teacher that this isn’t a hospital, and actually, this isn’t a hospital. I 253

understand, but I tend to pay attention to the child’s physical condition and disease.” Nurses also 254

realized the unique school community when they needed to adjust the school’s timetable in order 255

to provide nursing care. The other nurse said, “She [the TD child] is in a mainstream class. In the 256

class, she needs to join in the lessons together with her classmates. I wonder when I’m able to 257

provide her nursing care.” 258

Nurses came to perceive the limits of their status to care for TD children. Specifically, 259

they came to realize that for TD children in mainstream schools, the teachers are the primary 260

agents of support. A nurse reported, “In the school, the TD child and the teacher are at the center 261

and the nurse is a supporter. On the contrary, in the hospital, the patient and nurse are at the 262

center.” However, nurses also understood the teachers’ situations; teachers needed to educate all 263

students in the class, not only the TD child, and some teachers did not have experience in 264

educating children with disabilities or who were dependent on technology: “Teachers leave the 265

TD child to the nurses. Therefore they won’t know what is dangerous for the TD child unless I 266

tell them.” 267

Understanding the children. This category refers to how nurses come to understand the 268

larger picture regarding the TD children, including not only their physical aspects but also their 269

school and home lives. Nurses understood that the TD children were healthy by monitoring their 270

physical conditions and noticing their abilities and growth: “He [the TD child] is healthy. He has 271


a tracheotomy, but basically he is healthy physically and mentally even though he has the 272

tracheotomy.” Through interacting with the TD children and their parents, nurses came to 273

understand that they desired relationships with other children. Furthermore, nurses understood 274

that TD children and their classmates learned from each other and grew as a result. Take, for 275

example, the following observation by a nurse: 276

He [the TD child] spent time with classmates and performed the same activities with 277

them, except those that were dangerous or impossible for him. When classmates are in 278

higher grades, they understand what he can do and tell me that. 279

Through checking the TD children’s physical conditions, nurses came to understand the 280

influence of the school and home environments on their physical conditions. When nurses felt 281

the influence of the home environment and predicted the TD children’s futures, nurses realized 282

that children’s homes were their care bases: “I came to think that parents’ intentions for their 283

children’s care comes before anything else.” 284

Supporting self-care. After nurses understood the parents’ and TD children’s perspectives 285

on caring and that the TD children’s homes were children’s care bases, nurses began to find ways 286

of teaching TD children and their parents to care for themselves. They did this by providing 287

advice and observing their own health maintenance behavior in cooperation with teachers. One 288

nurse described: 289

At first, I tended to help her [the TD child] a lot. She has a physical disability. But I 290

didn’t consider [her]. I thought I needed to change her clothes and do catheterization as 291

fast as possible. I realized that we should support her in eating by herself when I saw a 292

teacher help her to eat by herself. I realized it was important. 293

Becoming a secure base. Having established relationships of mutual trust with the TD 294


children, nurses began listening to the children’s feelings and concerns and tried to become a 295

secure base for them. One nurse mentioned: 296

It’s mental care. She [the TD child] talked to me about daily happenings during urine 297

catheterization. She said, “A classmate said to me ‘You can’t walk’ and I felt frustrated 298

and cried and hit her.” She tends to feel at ease. So I listened to her. 299

Bridging. After nurses understood the school community, they tried to serve as a bridge 300

between teachers, school nurses, and the TD children. Nurses provided information about the TD 301

children’s physical condition to teachers and school nurses and took care of these children with 302

their cooperation. By doing so, nurses attempted to bring these children to the forefront of 303

teachers’ and school nurses’ minds, instill a sense of security among teachers in handling TD 304

children, and encourage teachers to ensure the children’s safety: “I explained to teachers about 305

the TD children’s physical condition. When they [the teachers] didn’t notice, I explained it to 306

them in greater detail.” Nurses shared parents’ concerns and bridged the gap between teachers 307

and parents so that both parties could understand the other’s perspectives, thereby improving the 308

relationship: 309

His mother sent me an email when she hesitated to tell his [the TD child’s] teacher 310

directly. So, I informed his teacher and we discussed his mother’s concerns together. I did 311

not speak with the mother myself, but I asked the teacher to talk to her. 312

Stage 3: Supporting children’s leaning with each other. In this stage, nurses came to 313

realize the importance of TD children’s learning and interaction with other children and the 314

meaning of supporting TD children in their learning and interaction with other children. As such, 315

they actively began to support TD children’s participation in educational activities and building 316

relationships with other children and realized the meaning of supporting TD children more. This 317


stage contains three categories: realizing the meaning of supporting TD children, supporting 318

participation in educational activities, and supporting the building of relationships with other 319

children. 320

Realizing the meaning of supporting TD children. By watching the growth of TD 321

children and their schoolmates, nurses came to realize how important it was for TD children to 322

learn and interact with other children in mainstream schools. One nurse described: 323

I saw that she [the TD child] was changing. By leaving her among her classmates, she is 324

trying to do [things] by herself and ask a classmate around her to get help when she has 325

difficulty, and [as a result] she gets more confidence in herself. I saw how she was 326

changing and I realized that it was important. 327

After realizing the importance of TD children’s learning and interaction with other children, the 328

nurses came to realize the meaning of their supporting TD children to learn and interact with 329

other children: 330

I felt that it was good for him [the TD child] to make the effort to go to school. I noticed I 331

had medical thoughts, the thoughts that nurses working in hospitals have, the thought that 332

it is best for him to be treated and get better. Outside of the hospital, he had fun, even if 333

his physical condition didn’t get better. His disease was incurable. I realized that nursing 334

was not only for treatment. 335

Nurses’ realization of the meaning of their support of TD children clarified two roles for 336

them: (1) supporting participation in educational activities, and (2) supporting the building of 337

relationships with other children. 338

Supporting participation in educational activities. Together with teachers, nurses began 339

actively supporting TD children’s participation in educational activities as soon as they 340


understood their roles in this practice. When nurses felt that the teachers were having difficulty 341

in interacting with children safely, they helped the teachers in providing educational activities. 342

Nurses were also careful not to disturb the children’s education while they were providing 343

nursing care: “The place where I suction her sputum is not a hospital room but a classroom. I 344

considered this to ensure that my actions did not disturb lessons.” Nurses discussed educational 345

activities with the teachers, parents, and the TD child and managed the content of educational 346

activities to expand the child’s participation without threatening his or her health and safety; one 347

nurse said: 348

His [the child dependent on the ventilator] mother wanted him to join swimming lessons, 349

but that is difficult to do without guidance. To consider how he could do this, his teacher 350

and I gathered the school principal and teachers to consider [this] together. 351

Nurses often found it difficult to decide whether TD children could join a given educational 352

activity with their classmates. Some nurses resolved this difficulty by putting themselves in the 353

place of the TD child. One nurse commented, “When I am at a loss, I follow his [the TD child’s] 354

standard. If I were him. What does he want to do? What kind of educational activities are better 355

for his physical condition?” They engaged in this practice more frequently as they came to better 356

understand the TD child. 357

Nurses reported that their mutually trusting relationships with teachers were the core of 358

their ability to support the TD children’s participation in educational activities (e.g., physical 359

education, athletic meets, swimming lessons, school trips). In other words, nurses felt secure in 360

their abilities to help because of these relationships. 361

Supporting the building of relationships with other children. Nurses and teachers 362

collaborated in supporting TD children in building relationships with other children. Nurses 363


mingled with children to provide chances to facilitate communication between the TD children 364

and other children. Often, nurses put themselves in the place of the TD children and spoke for 365

them, especially when they could not communicate verbally. Nurses also used their own 366

professional knowledge to assist other children in understanding the TD children and their 367

disabilities. One nurse commented: 368

I am a nurse. I thought it was necessary to have time to explain to the classmates about 369

her [the TD child’s] physical condition using expert knowledge. So I asked the 370

homeroom teacher to give me school hours to explain to her classmates. 371

On the other hand, nurses were careful not to give the TD children special treatment and 372

kept a distance while ensuring their safety, because nurses thought special treatment would 373

disturb the TD children’s communication with other children. One nurse mentioned: 374

When she [the TD child] plays happily with classmates, I think I should go away. 375

Conversely, when classmates are confused by what she is doing, they do not play with 376

her; I watch the situation and assess when I should intervene. It’s a conflict. 377

Nurses also paid attention to the children’s socialization. Nurses taught the TD children to 378

follow rules and greet others in order to build a relationship with other children smoothly. 379

Discussion 380

The present study revealed the role development of nurses caring for TD children who 381

attend mainstream schools. It consisted of three stages: Stage 1, “maintaining children’s physical 382

health;” Stage 2, “maintaining children’s physical and mental health;” and Stage 3, “supporting 383

children’s learning with each other.” Role development of these nurses meant realization of the 384

meaning of supporting TD children’s learning and interaction with other children. 385

Our findings indicate that nurses’ viewpoints gradually shifted from a focus on the TD 386


children’s physical conditions (Stage 1) to considering children’s futures, homes, and school 387

lives (Stage 2). In Stage 2, nurses developed a deeper understanding of the school community 388

and the TD children. Finally, in Stage 3, nurses realized the meaning of supporting the TD 389

children’s learning and interaction with other children. Previous research has indicated that 390

knowing the patient affects nurses’ abilities to engage in expert practice (Zolnierek, 2014). 391

Stages 2 and 3 are thought to reflect nurses’ development toward a stage of proficiency wherein 392

nurses can practice with a holistic understanding of the patient (Benner et al., 2009). In Stage 3, 393

nurses considered the situation from the TD children’s perspectives and built mutually trusting 394

relationships with teachers, which helped them support these children’s participation in 395

educational activities without confusion. In Stage 3, nurses were aware not only of what to do 396

but also of how to do it and were able to develop orchestrated teamwork, which fits with 397

definitions of expert practice (Benner et al., 2009). Benner et al. (2009) described the nature of 398

skill acquisition in critical care nursing practice. Although the workplace is different, our 399

findings were similar. We suggest that nurses’ role development has similar stages regardless of 400

the workplace. 401

Supporting TD children’s participation in educational activities and the building of 402

relationships with other children, by considering situations from TD children’s perspectives and 403

building mutually trusting relationships with teachers, could constitute expert practices for nurses 404

caring for TD children in mainstream schools. Adults’ and peers’ understanding of the needs and 405

abilities of individual children with disabilities is known to be a factor influencing the extent to 406

which children participated in activities (Kramer, Olsen, Mermelstein, Balcells, & Liljenquist, 407

2012). In our study, nurses supported teachers and children in understanding the TD children 408

using their expert knowledge and skills. In addition, nurses managed educational activities via 409


discussions with teachers, parents, and TD children in order to facilitate safe participation of TD 410

children in school activities. Our study demonstrated that by developing nurses’ roles, nurses 411

were able to promote TD children’s participation in their school activities using their expert 412

knowledge and skills. 413

Our finding that nurses learned how to interact with children, understood the school 414

community and the children, and realized the meaning of supporting TD children, which in turn, 415

developed their roles, is similar to previous studies, which demonstrate that knowledge and skill 416

acquisition are an important factor in nurses’ role development (Ellis & Chater, 2012; Rasmussen 417

et al., 2014). A novel finding of our study is that nurses learned not only to take care of TD 418

children and to read their signals but also to interact with the children in an educational capacity, 419

even though these skills do not fall under the purview of nursing practice. This suggests that the 420

necessary knowledge and skills for nurses’ role development are not restricted to the nursing 421

sphere. 422

Nurses learned how to interact with children through building relationships of mutual 423

trust with teachers and parents, and mainly watching their practices and getting advice from them. 424

This finding is similar to a report suggesting that work community participation and engagement 425

in interpersonal relationships are important in order to learn from work (Skår, 2010). Initially, the 426

participants believed themselves to be solely present as nursing professionals in the schools. 427

However, they did not cling to this status, and communicated positively in order to build 428

relationships of mutual trust and work harmoniously in the school community. Nurses’ 429

professional competencies and interpersonal caring attributes—including honesty, 430

trustworthiness, confidentiality, commitment to providing the best care, authenticity, sensitivity, 431

humility, and the ability to see the larger picture—are important in developing trust in nurse–432


patient relationships (Dinç & Gastmans, 2013). In addition, this study suggests that it is 433

important for nurses who work in mainstream schools to have the flexibility gained from a lack 434

of concern over their statuses in order to build relationships of mutual trust with teachers and 435

children, learn more in their workplaces, and develop their roles. 436

Limitations 437

There were some limitations to this study. First, participants were nurses who provided 438

nursing care in Japanese mainstream schools. The finding presented here cannot be generalized 439

to different countries. Second, this study relied mainly on data from interviews. We did not 440

observe all participants’ actual practices. In spite of these limitations, this study is significant 441

because it reveals the role development of nurses caring for TD children in mainstream schools 442

for the first time and suggests that their developed roles can improve TD children’s participation 443

in educational activities. 444

How Might This Information Affect Nursing Practice? 445

The places where pediatric nurses play an active role are expanding. When these nurses 446

begin working in mainstream schools, we believe that the findings of this study will be helpful in 447

developing their roles. Our findings suggest that nurses should not only exhibit their expertise 448

but also go beyond their nursing status in order to build relationships of mutual trust with 449

teachers and children and learn on the job in mainstream schools. 450

This study showed that when nurses caring for TD children in mainstream schools 451

develop their roles, there is a possibility of expanding the participation of TD children in their 452

school activities and realizing inclusive education in mainstream schools. This information will 453

support policymakers as they strive to create innovative policies for providing nursing care in 454

mainstream schools. 455

456


References 457

All-Party Parliamentary Group on Global Health and the Africa All-Party Parliamentary Group. 458

(2012, July 11). All the talent. Global Health Workforce Alliance. Retrieved from 459

http://www.who.int/workforcealliance/knowledge/resources/appggh_report2012resource/460

en/ 461

Benner, P., Tanner, C., & Chesla, C. (2009). Expertise in nursing practice caring, clinical 462

judgment & ethics (2nd ed.). New York, NY: Springer Publishing Company. 463

Boström, E., Hörnsten, A., Lundman, B., Stenlund, H., & Isaksson, U. (2013). Role clarity and 464

role conflict among Swedish diabetes specialist nurses. Primary Care Diabetes, 7, 207–465

212. doi: 10.1016/j.pcd.2013.04.013 466

Clancy, C., Oyefeso, A. & Ghodse, H. (2006). Role development and career stages in addiction 467

nursing: An exploratory study. Journal of Advanced Nursing, 57(2), 161–171. doi: 468

10.1111/j.1365-2648.2006.04088.x 469

Dinç, L., & Gastmans, C. (2013). Trust in nurse-patient relationships: A literature review. 470

Nursing Ethics, 20(5), 501–516. doi: 10.1177/0969733012468463 471

Ellis, I., & Chater, K. (2012). Practice protocol: Transition to community nursing practice 472

revisited. Contemporary Nurse, 42(1), 90–96. doi: 10.5172/conu.2012.42.1.90 473

Glaser B., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative 474

research. Mill Valley, CA: Sociology Press. 475

Heaton, J., Noyes, J., Sloper, P., & Shah, R. (2005). Families’ experiences of caring for 476

technology-dependent children: A temporal perspective. Health and Social Care in the 477

Community, 13(5), 441–450. doi: 10.1111/j.1365-2524.2005.00571.x 478

Heitz, L. J., Steiner, S. H., & Burman, M. E. (2004). RN to FNP: A qualitative study of role 479


transition. Journal of Nursing Education, 43(9), 416–420. 480

Japan Ministry of Education, Culture, Sports, Science and Technology. (2009). Heisei 20 nendo 481

tokubetushiengakko ni kansuru chosakekka ni tsuite. [Report on survey findings 482

regarding nursing care in special needs schools in Japan] Retrieved from 483

http://www.mext.go.jp/a_menu/shotou/tokubetu/material/__icsFiles/afieldfile/2012/07/04484

/1260767_1.pdf 485

Japan Ministry of Education, Culture, Sports, Science and Technology. (2014). Heisei 25 nendo 486

tokubetushiengakko tou no iryoutekikea ni kansuru chosakekka ni tsuite. [Report on 487

survey findings regarding nursing care in special needs schools and mainstream schools 488

in Japan] Retrieved from 489

http://www.mext.go.jp/a_menu/shotou/tokubetu/material/1345112.htm 490

Jones, M. L. (2005). Role development and effective practice in specialist and advanced practice 491

roles in acute hospital settings: Systematic review and meta-synthesis. Journal of 492

Advanced Nursing, 49(2), 191–209. doi: 10.1111/j.1365-2648.2004.03279.x 493

Kinoshita, Y. (2003). Grounded theory approach no jissen-shitsuteki kenkyu e no sasoi [Practice 494

of grounded theory approach]. Tokyo, Japan: Koubundou. 495

Kirk, S. (2010). How children and young people construct and negotiate living with medical 496

technology. Social Science & Medicine, 71, 1796–1803. doi: 497

10.1016/j.socscimed.2010.07.044 498

Kramer, J. M., Olsen, S., Mermelstein, M., Balcells, A., & Liljenquist, K. (2012). Youth with 499

disabilities' perspectives of the environment and participation: A qualitative meta-500

synthesis. Child: Care, Health and Development, 38(6), 763–777. doi: 10.1111/j.1365-501

2214.2012.01365.x 502

http://www.mext.go.jp/a_menu/shotou/tokubetu/material/1345112.htm


Matsumura, K., Oouchi, S., Sasamoto, K., Nishimaki, K., Oda, Y., Toushima, S., … Kameno, S. 503

(2009). Syochugakko ni okeru tokubetsushienkyoiku heno rikai to taio no jujitsu ni 504

muketa shikuchoson kyoikuiinkai no torikumi [Municipality education boards’ efforts 505

towards the understanding and effective handling of special needs education in 506

elementary and junior high schools]. Bulletin of the National Institute of Special Needs 507

Education, 36, 3–16. 508

Miller, K., Joseph, L., & Apker, J. (2000). Strategic ambiguity in the role development process. 509

Journal of Applied Communication Research, 28(3), 193–214. 510

Rasmussen, P., Henderson, A., & Muir-Cochrane, E. (2014). Conceptualizing the clinical and 511

professional development of child and adolescent mental health nurses. International 512

Journal of Mental Health Nursing, 23, 265–272. doi: 10.1111/inm.12039 513

Raymond, J. A. (2009). The integration of children dependent on medical technology into public 514

school. The Journal of School Nursing, 25(3), 186–194. doi: 10.1177/1059840509335407 515

Shimizu, F. (2014). Tsujogakko ni oite iryotekikea ni kakawaru kangoshi no haichi ya koyojokyo 516

no zenkokuchosa [Actual conditions of the postings and employment of nurses for 517

technology-dependent children at mainstream schools in Japan]. Journal of Child Health 518

Care, 73(2), 360–366. 519

Shimizu, F., & Katsuda, H. (2014). Teachers’ perceptions of the role of nurses: Caring for 520

children who are technology-dependent in mainstream schools. Japan Journal of Nursing 521

Science. Advance online publication. doi: 10.1111/jjns.12046 522

Simmons, D. R. (2002). Autonomy in practice: A qualitative study of school nurses' perceptions. 523

The Journal of School Nursing, 18(2), 87–94. 524

Skår, R. (2010). How nurses experience their work as a learning environment. Vocations and 525


Learning, 3(1), 1–18. doi: 10.1007/s12186-009-9026-5 526

United Nations Educational, Scientific and Cultural Organization. (2009). Policy guidelines on 527

inclusion in education. Retrieved from 528

http://unesdoc.unesco.org/images/0017/001778/177849e.pdf#search='policy+guideline+o529

n+inclusion+in+education' 530

United States Congress, Office of Technology Assessment. (1987). Technology-dependent 531

children: Hospital v. home care—A technical memorandum, OTA-TM-H-38. Washington, 532

DC: U.S. Government Printing Office. 533

Zolnierek, C. D. (2014). An integrative review of knowing the patient. Journal of Nursing 534

Scholarship, 46(1), 3–10. doi: 10.1111/jnu.12049 535


Table 1

Characteristics of the Participants (n = 21)

Characteristics n Mean Range

Gender

Male 0

Female 21

Age (years) 45.5

30s 3

40s 13

50s 3

60s 2

Professional Education

Bachelor’s degree 1

Associate’s degree 4

Diploma 12

No response 4

Years of Experience

Clinical experience (except at schools) 12.4 3–48

≥3 to <5 years 3

≥5 to <10 years 7

≥10 to <20 years 9

≥20 years 2

Pediatric nursing (except at schools) (N =

8)

7.9 1–20

<3 years 2

≥3 to <5 years 2

≥5 to <10 years 1

≥10 years 3

Mainstream schools 5.4 2.6–9

≥2 to <5 years 11

≥5 to <10 years 10

Municipality population size of workplace

<50,000 4

50,000–500,000 13

>500,000 4

School size of workplace

<100 children 1

≥100 to <300 children 6



≥700 children 3


Table 2

Categories and Concepts

Category Concept

Maintaining physical health Providing nursing care

Ensuring the TD child’s safety

Monitoring the TD child’s physical condition

Providing care for rehabilitation

Feeling confused Being confused about the extent of care

Being confused about the content of care

Hesitation in being concerned with education

Building relationships of mutual

trust

Harmonizing with the school community

Going beyond the status of nurses

Loving the TD child as their own

Listening to and sharing parents’ concerns

Feeling a sense of security

Learning how to interact with

children

Learning how to best provide care

Learning the TD child’s signals

Learning how to interact with children in an

educational capacity

Understanding the school

community

Realizing education is foremost

Being conscious of the school’s timetable

Realizing teachers are the primary agents of support

Understanding the teachers’ situation

Understanding the children Understanding the TD child’s health

Understanding the TD child’s and parents’ desires for

school life

Noticing children’s growth

Realizing home is the care base

Supporting self-care Advising the TD child and parents on self-care

Observing the TD child’s behavior on self-care

Becoming a secure base Becoming a secure base

Bridging Bridging the gap between teachers and the TD child

Bridging the gap between parents and teachers

Realizing the meaning of

supporting TD children

Realizing the importance of the TD child’s learning

and interaction with other children

Realizing the meaning of supporting the TD child’s

learning and interaction with other children

Supporting participation in

educational activities

Not disturbing educational activities

Helping with educational activities

Managing educational activities

Considering situations from the TD child’s perspective

Supporting the building of

relationships with other children

Paying attention to the TD child’s socialization with

other children

Not treating the TD child differently

Supporting children’s understanding

Note. TD, technology-dependent


Figure 1. Interview Guide

Content of nursing care

1. How do you take care of technology-dependent children in a mainstream school?

2. What do you consider when you provide nursing care in a school?

3. Who do you contact while you are working in a school? What is the purpose of this

contact?

4. Has the content of care changed? If yes, how has it changed?

Role of nurses

5. What do you think your role is for the technology-dependent child in a mainstream

school?

6. Has your role perception changed? If yes, how did your perception change? What

changed your perception?

Change of view

7. Through this job, has your nursing view changed? If yes, how has it changed?


This is the accepted version of the following article: Journal for Specialists in Pediatric Nursing,

which has been published final form at doi: 10.1111/jspn.12105.

Documents

Role Development of Nurses for Technology …...91 reported, but only among nurses working in hospitals (Benner, Tanner, & Chesla, 2009) and the 92 community (Clancy, Oyefeso, & Ghodse,